The Effectiveness of Cognitive Behavioral Therapy for PTSD in New York City Transit Workers: A Preliminary Evaluation
Lowinger, Robert Jay, Rombom, Howard, North American Journal of Psychology
Cognitive behavior therapy (CBT) is based on the theory that behavior is determined by the way in which people think about themselves and their roles in the world; the therapy is aimed at correcting cognitive distortions and the self-defeating behavior that result from them (Kaplan & Sadock, 2005). The major tenets of CBT and its empirical support are reviewed in a number of sources (e.g., Butler, Chapan, Forman, & Beck, 2006; Corey, 2005). CBT is the most popular psychological treatment for post-traumatic stress disorder, generally focusing on reduction of PTSD symptoms and improvement of quality of life in spite of often chronic symptoms (Rademaker, Vermetten, & Kleber, 2009). While there are several studies indicating the efficacy of CBT for the clinical treatment of PTSD (see Mendes, Mello, Ventura, Passarela, & Mari, 2008), this study is distinctive in that it explores the usefulness of CBT in a population of transit workers who experienced a traumatic incident on the job. Although a number of studies have looked at the medical and psychological impact of trauma on transit workers (e.g., Cothereau, et al., 2004), we were unable to identify any published studies on the use of CBT for treating PTSD in this population. This is a particularly important population to assess relative to treatment efficacy due to the large volume of traumatic incidents that transit workers are exposed to over the course of their entire employment, the relatively high incidence rate of PTSD in this population, as well as the high motivation of this population to overcome the symptoms of PTSD so that they are able to return to work (Cothereau, et al. 2004; Limosin et al., 2005; Yum et al., 2006).
Existing studies of CBT treatment efficacy are based on an experimental paradigm in which CBT is compared with alternative treatments or a control group receiving no treatment in order to demonstrate efficacy (e.g., Anderson & Grunert, 1997; Davis & Wright, 2007; Foa et. al, 2005). Such studies reduce the influence of confounding variables, allow for comparison with other treatment modalities by the use of suitable control groups, as well as utilize standardized measures of treatment outcome. However, studies of the efficacy of CBT individual therapy typically employ manualized treatments of relatively short duration (less than six months) (e.g., Anderson & Grunert, 1997; Davis & Wright, 2007; Foa et. al, 2005) in order to provide for standardization and reduce study costs; although studies assessing the efficacy of group modalities (e.g., Alvarez, et al., 2011; Rademaker, et al., 2009) might employ treatments of longer duration. Furthermore, these studies depend on the administration of a battery of standardized measures, which are commonly administered only at the beginning and end of treatment, disregarding any measurement of client progress during the course of the treatment.
While experimental studies have much to offer in terms of scientific validity, they may not be representative of a good deal of clinical practice in which treatment protocols, the duration of treatment, as well as the assessment of client progress are often based on a combination of clinical and informal client judgment. The present study explores the efficacy of CBT conducted in a large outpatient behavioral medicine psychological practice. In this setting, psychologists use CBT more eclectically than in a manualized approach (for example, sometimes using exposure techniques and sometimes not) depending upon clinical judgment as to what might or might not be helpful for a particular client in a particular session. Furthermore, treatment duration is highly variable based upon the client's decision to terminate in consultation with the treating psychologist. Also, measures of treatment efficacy are often limited to the clinical judgment of the treating therapist's assessment of client progress on a comprehensive list of relevant symptoms rather than on standardized measures with demonstrated psychometric characteristics. …